Symbolism Versus Substance

Chris Weigant

The House of Representatives, as expected, just voted to repeal the landmark healthcare law, which President Obama signed less than a year ago. This vote was a symbolic victory for Republicans, but not any sort of substantial change. To truly repeal the law, the Senate would have to also pass the bill the House just passed, and then both houses would have to muster a two-thirds majority vote to overcome Obama’s veto. None of which is going to happen. Democrats still control the Senate, and Harry Reid has all but pronounced the bill “dead on arrival” in his chamber, meaning that today’s House vote is the only victory (and a symbolic one, at that) Republicans should expect in their mad dash to repeal healthcare reform.

Which is probably fine with them. House Republicans know full well that their vote today is nothing more than empty symbolism — but it is important empty symbolism, as far as they’re concerned. The Tea Party Republicans who campaigned on the issue of “Repeal!” have proven their bona fides to their fervent supporters, and now they can throw up their hands and blame the expected inaction on Senate Democrats — thus paying no real political price for spending time on such a Pyrrhic victory. In other words, Republicans in the House have won a single “news cycle” — even though the more honest among them fully admit that the effort is ultimately going nowhere.

The entire exercise is nothing more than “politics for politics’ sake,” really. Which is fine — both political parties do this sort of thing at times, to toss some symbolic red meat to their base. And as political red meat goes, this was the juiciest symbolism Republicans had at their disposal. The last time Republicans engaged in such potent symbolism was when Newt Gingrich took control of the House, and quickly passed all the items on his “Contract With America” — only to see virtually all of the bills screech to a halt in the Senate.

Republicans can bask in this symbolic victory, but when Congress really gets down to business (after next week’s State of the Union speech by President Obama), things are going to get a bit more complicated. The campaign slogan many of these Republicans ran on (in relation to what they called “Obamacare”) was “Repeal and replace.” In other words, throw the whole thing out and then start over and replace it with the wonderfulness of the Republican plan on healthcare reform. The only problem with this scenario (other than the fact that repeal isn’t going anywhere after the bill leaves the House) is that there is no “Republican plan on healthcare.” It doesn’t exist.

This is where the substance comes into things, after the symbolism becomes yesterday’s news. Republicans aren’t just going to pat themselves on the back for their symbolic repeal vote and then move on to other things — they’re going to try to tinker with healthcare all year long, apparently. This action will happen on several fronts. The first of these is using Congress’ traditional “power of the purse” to starve “Obamacare” of the funds it needs. Republicans may try to write into the Health and Human Services budget a ban on using one thin dime to implement the healthcare reform law passed last year. This will likely result in only symbolic victories, since (again) the Senate is going to have its say on the budget, and since many of the provisions of the healthcare reform law aren’t actual budget issues and thus can’t be gotten rid of with the blunt instrument of Congress de-funding them.

The next effort is going to happen (if it does) when Republicans mull over exactly how they want to tinker with the existing law in various House committees. This is where they’re going to have to admit (implicitly, at least) that some of the provisions of the new law are actually quite popular with the public. Now that they’ve made their symbolic point with today’s repeal vote, Republicans will be able to tell Tea Party voters: “We tried to get rid of the whole thing, but now we’re going to have to change it piecemeal.” Conveniently, the pieces that the public likes the most will likely escape such efforts to rewrite the law. About the biggest change that could actually make it through Congress might be getting rid of the individual mandate — which has few defenders, even among Democrats.

Other than repealing the mandate, however, things get complicated awfully fast. It wouldn’t surprise me to see Republicans struggle with exactly what to do on healthcare for months. There’s a reason Democrats took more than a year to hammer something out, and the reason is that there simply aren’t easy answers to the problems in the system. So Republicans are going to spend an awful lot of time figuring out which tactic to try in their overall efforts to get rid of “Obamacare.”

It remains to be seen what the public is going to think about this effort. Polling is pretty evenly split on the Democratic healthcare reform, and it’s probably a safe bet to say that polling will likely be all over the map on the ideas Republicans come up with. But the overarching question will likely not even be asked by the pollsters — at what point does the public begin to wish that Republicans end their “Obamacare” obsession, and get on with some other important business? After all, we’ve spent a goodly portion of the past two years on the healthcare reform debate, and if Republicans decide to devote a lot of time to rehashing the issue for the next two years, at some point the public is going to get a little tired of hearing about the subject (if they’re not already).

This week in the House was set aside for symbolism. The Republicans achieved the symbolic victory they had planned today. Which is all fine and good — as I said, both parties occasionally delve into such blatant political gamesmanship. Congress traditionally doesn’t get much done in January anyway, other than getting sworn in and listening to the State of the Union speech. And now Republicans have their symbolism to talk about next week, after Obama speaks to a joint session of Congress and the country at large. But that will be the only tangible result of today’s action in the House — a talking point for Republicans to use for a while.

In one sense, this week will mark the end of Republicans’ political coyness and over-reliance on symbolism. Because after the president’s speech, they’re going to have to actually put some cards on the table. Substantive cards — not mere symbolism. Republicans are going to have to finally tell the public how exactly they’re going to be cutting spending from the federal budget, instead of blithely insisting that they’ll find enough “waste, fraud, and abuse” to balance the budget in a year or so. They’re going to have to start coming up with actual legislative ideas on the budget, and on healthcare reform, and on a number of other subjects and issues. Up until now, it has been “campaign season,” where politicians can get away with gauzy promises without answering any questions about specifics. This week marks the end of this happy-talk season, and the beginning of the “nuts-and-bolts” season of writing their campaign promises into actual legislation.

So Republicans should enjoy their symbolic moment in the sunshine. It certainly is fun to pass a bill that everyone knows isn’t going any further. But the time for such symbolism is fast drawing to a close. And the substance that follows is not going to be anywhere near as much fun for the Republicans, as they will be forced to present concrete proposals to the public on how to solve the nation’s problems. Republicans should indeed enjoy their symbolic holiday while they can, because what comes next is going to be a lot more real than tossing symbolic red meat to their base.

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Getting Someone to Psychiatric Treatment Can Be Difficult and Inconclusive


That question is as difficult to answer today as it was in the years and months and days leading up to the shooting here that left 6 dead and 13 wounded.

Millions of Americans have wondered about a troubled loved one, friend or co-worker, fearing not so much an act of violence, but — far more likely — self-inflicted harm, landing in the streets, in jail or on suicide watch. But those in a position to help often struggle with how to distinguish ominous behavior from the merely odd, the red flags from the red herrings.

In Mr. Loughner’s case there is no evidence that he ever received a formal diagnosis of mental illness, let alone treatment. Yet many psychiatrists say that the warning sings of a descent into psychosis were there for months, and perhaps far longer.

Moving a person who is resistant into treatment is an emotional, sometimes exhausting process that in the end may not lead to real changes in behavior. Mental health resources are scarce in most states, laws make it difficult to commit an adult involuntarily, and even after receiving treatment, patients frequently stop taking their medication or seeing a therapist, believing that they are no longer ill.

The Virginia Tech gunman was committed involuntarily before killing 32 people in a 2007 rampage.

With Mr. Loughner, dozens of people apparently saw warning signs: the classmates who listened as his dogmatic language grew more detached from reality. The police officers who nervously advised that he could not return to college without a medical note stating that he was not dangerous. His father, who chased him into the desert hours before the attack as Mr. Loughner carried a black bag full of ammunition.

“This isn’t an isolated incident,” said Daniel J. Ranieri, president of La Frontera Center, a nonprofit group that provides mental health services. “There are lots of people who are operating on the fringes who I would describe as pretty combustible. And most of them aren’t known to the mental health system.”

Dr. Jack McClellan, an adult and child psychiatrist at the University of Washington, said he advises people who are worried that someone is struggling with a mental disorder to watch for three things — a sudden change in personality, in thought processes, or in daily living. “This is not about whether someone is acting bizarrely; many people, especially young people, experiment with all sorts of strange beliefs and counterculture ideas,” Dr. McLellan said. “We’re talking about a real change. Is this the same person you knew three months ago?”

Those who have watched the mental unraveling of a loved one say that recognizing the signs is only the first step in an emotional, often confusing, process. About half of people with mental illnesses do not receive treatment, experts estimate, in part because many of them do not recognize that they even have an illness.

Pushing such a person into treatment is legally difficult in most states, especially when he or she is an adult — and the attempt itself can shatter the trust between a troubled soul and the one who is most desperate to help. Others, though, later express gratitude.

“If the reason is love, don’t worry if they’ll be mad at you,” said Robbie Alvarez, 28, who received a diagnosis of schizophrenia after being involuntarily committed when his increasingly erratic behavior led to a suicide attempt. At the time, he said, he was living in Phoenix with his parents, who he was convinced were trying to kill him. In Arizona it is easier to obtain an involuntary commitment than in many states because anyone can request an evaluation if they observe behavior that suggests a person may present a danger or is severely disabled (often state laws require some evidence of imminent danger to self or others).

But there are also questions about whether the system can accommodate an influx of new patients. Arizona’s mental health system has been badly strained by recent budget cuts that left those without Medicaid stripped of most of their services, including counseling and residential treatment, though eligibility remains for emergency services like involuntary commitment. And the state is trying to change eligibility requirements for Medicaid, which would potentially reduce financing further and leave more with limited services.

Still, people who have been through the experience argue that it is better to act sooner rather than later. “It’s not easy to know when we could or should intervene but I would rather err on the side of safety than not,” said H. Clarke Romans, executive director of the local chapter of the National Alliance on Mental Illness, an advocacy group, who had a son with schizophrenia.

The collective failure to move Mr. Loughner into treatment, either voluntarily or not, will never be fully understood, because those who knew the young man presumably wrestled separately and privately about whether to take action. But the inaction has certainly provoked second-guessing. Sheriff Clarence Dupnik of Pima County told CNN last Wednesday that Mr. Loughner’s parents were as shocked as everyone else. “It’s been very, very devastating for them,” he said. “They had absolutely no way to predict this kind of behavior.”

Linda Rosenberg, president of the National Council for Community Behavioral Healthcare, said, “The failure here is that we ignored someone for a long time who was clearly in tremendous distress.” Ms. Rosenberg, whose group is a nonprofit agency leading a campaign to teach people how to recognize and respond to signs of mental illness, added, “He wasn’t someone who could ask for help because his thinking was affected, and as a community no one said, let’s stop and make sure he gets help.”

At the University of Arizona, where a nursing student killed three instructors on campus eight years ago before killing himself, feelings of sadness and anger initially mixed with some guilt as the university examined the missed warning signs.

The overhauled process for addressing concerns is now more responsive, even if there are sometimes false alarms, said Melissa M. Vito, vice president for student affairs. “I guess I’d rather explain why I called someone’s parents than why I didn’t do something,” she said.

Many others feel the same way.

Four years ago Susan Junck watched her 18-year-old son return from community college to their Phoenix home one afternoon and, after preparing a snack, repeatedly call the police to accuse his mother of poisoning him. She assumed it was an isolated outburst, maybe connected to his marijuana use. In the coming months, though, her son’s behavior grew more alarming, culminating in an arrest for assaulting his girlfriend, who was at the center of a number of his conspiracy theories.

“I knew something was wrong but I literally just did not understand what,” Ms. Junck, 49, said in a recent interview. “It probably took a year before I realized my son has a mental illness. This isn’t drug related, this isn’t bad behavior, this isn’t teenage stuff. This is a serious mental illness.”

Fearful and desperate, she brought her son to an urgent psychiatric center and — after a five-hour wait — agreed to sign paperwork to have him involuntarily committed as a danger to himself or others. Her son screamed for her help as he was carried off. He was diagnosed with paranoid schizophrenia and remains in a residential treatment facility.

This week Erin Adams Goldman, a suicide prevention specialist with a mental health nonprofit organization in Tucson, is teaching the first local installment of a course that is being promoted around the country called mental health first aid, which instructs participants how to recognize and respond to the signs of mental illness.

A central tenet is that if a person has suspicions about mental illness it is better to open the conversation, either by approaching the individual directly, someone else who knows the person well or by asking for a professional evaluation.

“There is so much fear and mystery around mental illness that people are not even aware of how to recognize it and what to do about it,” Ms. Goldman said. “But we get a feeling when something is not right. And what we teach is to follow your gut and take some action.”

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Long-Term Antidepressant Treatment Contributes To Significant Increases In Weight Gain And Obesity

On January 18, 2011, in Depression, Medication, by Christopher Fisher, PhD

This study demonstrates that patients using antidepressant medication continuously, mostly serotonin-selective reuptake inhibitors (SSRIs), show significantly more (abdominal) overweight and obesity than those using them intermittently or not at all. Compared with SSRIs, other types of antidepressant medication used (e.g. tricyclic ADs) did not have a significant impact on the anthropometric measures (i.e., measurement of of human physical variations).

In a study published in the last 2010 issue of Psychotherapy and Psychosomatics, a group of researchers of the University of Amsterdam presents new findings on the relationship between weight and recurrent depression.

The literature on the relation between obesity and the recurrent type of major depressive disorder (MDD-R; having had at least 2 major depressive episodes) is limited and equivocal. Most studies on depression and obesity did not distinguish between single and recurrent episodes. However, this distinction may be important because depression is increasingly considered a chronic recurrent disorder with various levels of interepisodic functioning, and evidence is growing that the recurrent type is a distinct one.

Most studies on the relation between depression and obesity did not control for antidepressant (AD) medication use, although a substantial part (20 – 60%) of the recurrently depressed patients use ADs for lengthy periods of time. This study elaborates on their findings by focusing on the relation between obesity and MDD-R and the association between long-term use of ADs and obesity.

To be eligible for this study, patients had to meet the following criteria: (a) at least 2 major depressive episodes in the past 5 years (DSM IV), (b) current remission status, according to DSM-IV criteria, for longer than 10 weeks and no longer than 2 years before, and (c) Hamilton Rating Scale for Depression of <10.

At 2 years, follow-up assessment anthropomorphic parameters were collected of 134 subjects.

To assess relapse/recurrence, the Structured Clinical Interview for DSM-IV (SCID-I) was used. Regarding the use of ADs, two groups were distinguished: those who used Ads throughout the entire 2-year study period (n = 46) and those who did not use ADs continuously, but intermittently (n = 49) or not at all (n = 39). Differences between these groups in BMI, waist circumference, and waist-to-hip ratio were tested stratified by gender.

Overweight and obesity occurred more often in patients with recurrent depression than in the reference group, although statistical significance was reached in women only (74% of this sample). Within the MDD-R patient group, serotonin-selective reuptake inhibitors (SSRIs) were the most commonly used type of AD among the continuous AD users. Compared with SSRIs, other types of ADs used (e.g. tricyclic ADs) did not have a significant impact on the anthropometric measures.

The mean AD equivalent correlated positively with both waist circumference (p = 0.006) and waist-to-hip ratio (p = 0.004), but not with BMI. In addition, mean waist circumference and waist-to-hip ratio scores were consistently higher amongst the continuous AD users compared to intermittent and no AD users. Patients using ADs continuously, mostly SSRIs, show significantly more (abdominal) overweight and obesity than those using them intermittently or not at all. Compared with SSRIs, other types of ADs used (e.g. tricyclic ADs) did not have a significant impact on the anthropometric measures. The authors did find, however, a small association between AD equivalent dosage and waist circumference and waist-to-hip ratio.

In general, a better understanding of the relationship between obesity and depression that includes understanding the beneficial and adverse effect of psychotropics on appetite, eating behaviour, body weight, and metabolism should improve our ability to prevent and treat both obesity and depression. Thereby, ideally persontailored interventions can be developed, including effective nonpharmaceutical preventive strategies for recurrent depression and extra physical activities with – as added benefit – protection against AD-induced weight gain.

Material adapted from Journal of Psychotherapy and Psychosomatics.

Lok, A.; Visscher, T.L.S.; Koeter, M.W.J.; Assies, J.; Bockting, C.L.H. ; Verschuren, W.M.M. ; Gill, A. ; Schene, A.H. The ‘Weight’ of Recurrent Depression: A Comparison between Individuals with Recurrent Depression and the General Population and the Influence of Antidepressants. Psychother Psychosom 2010;79:386-388.

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Can You Be Psychologically Healthy In Today’s World?

by Douglas LaBier, Ph.D.

The aftermath of the Tucson shootings is likely to spawn new discussion about serious mental illness and its legal implications. Coincidentally, the mental health establishment has been debating what to include or exclude as a mental and emotional disorder, for the forthcoming revision of the Diagnostic and Statistical Manual of Mental Disorders. For example, one controversy is whether to remove narcissism as a bonafide disorder.

In contrast to discussion about mental disorders, I think we’ve neglected its flip side: What constitutes psychological health in today’s world? What does it look like? And how can you promote it in your own life, your children and in society?

These questions loom large because the most psychologically healthy people and societies will be best equipped to create and sustain well-being, security and success in the tumultuous road we’re now traveling on.

Take a look: At the start of this second decade of the 21st Century our lives and institutions are reeling, trying to cope with an interconnected, unpredictable world turned upside down by the events of the first decade: terrorism that’s come home to roost; economic meltdown at home and abroad; rapid rise of previously “underdeveloped” nations; and in our social and political spheres, the rise of hatred, bigotry and intolerance, as Pima County Sheriff Clarence Dupik commented on following the Tucson shootings. This upheaval has fueled what I described in recent posts a “social psychosis” that’s locked in conflict with a societal need to serve the common good.

The problem is that we know what severe mental illness as well as “garden variety” neurotic conflicts look like in daily life. Those have become more prevalent in the current climate. But what we think of as psychological health is pretty vague. Moreover, it’s a 20th Century view that doesn’t fit in the new world environment.

That is, psychological health has been pretty much defined as successful resolution and management of childhood traumas and conflicts; coping with stress and adapting to the world around you, as an adult. The problem is, that view has assumed a relatively stable and static world. One in which you can anticipate the kinds of changes or events that might occur. And when they do, a healthy, resilient person could bounce back to the previous equilibrium that existed. But today, there’s no longer any equilibrium to return to. Psychological health requires living with disequilibrium.

Moreover, the 20th Century view equated psychologically healthy with adapting to the values and behavior that were culturally rewarded.  For example, adversarial competition; power-seeking for oneself; consuming material goods; living with trade-offs between your personal values and outward behavior; depleting resources in disregard for future generations. And that didn’t even work so well in the 20th Century: Some years ago I documented the emotional downside of with this kind of “successful” adaptation, in Modern Madness.

More recently, the Huffington Post blogger Tijana Milosevic described, from her European perspective, the negative side of American’s workaholism and hyper-focus on careerism. Economists and business writers such as Umair Haque in his Harvard Business Review blog and new book, The New Capitalist Manifesto, are also criticizing the 20th Century model of success and well-being as undermining positive development of our institutions in today’s current world.

In short, the prevailing old model creates, rather than diminishes psychological dysfunction and disturbance. It provides no useful guidance towards healthy living today, when people’s careers are uncertain, businesses struggle to stay afloat, relationships shatter with changing life goals and personal values, affairs and divorce; and when the public is confused and adversarial about the role of government in people’s lives. Moreover, old “truths” in several areas are found either to don’t work or to reflect established beliefs rather than actual evidence, as a recent New Yorker article revealed. Given all this, here’s some suggestions for beginning to redefine and rethink the essentials for a psychologically healthy life in the world we now live in. They reflect the likelihood that people who thrive in this new era will share some common features.

Overall, think of psychological health as an overall mentality of using emotional, cognitive, creative and relationship capacities in ways that help sustain and enhance the well-being of all, based on the recognition that all lives are interconnected and interdependent.

Put differently, this view of health reflects embracing a set of values — what a person believes in as important or vital in life; what he or she wants to use their powers for. For example, someone’s values might include, self-aggradizement, subjugation of others, power-lust and so forth. Such values fuel unhealthy behavior because they undermine rather than enhance well-being for all people. Ultimately, they lead to some form of dysfunction in relationships and career.

In contrast, values that are the underpinnings of psychological health include, for example, positive, supportive engagement with and respect toward diverse people; actions that contribute to the well-being of all, not just oneself; collaboration and compromise to achieve shared goals; self-regulation of stress through honest self-examination and reflection.

Values are a foundation for health. Then, several capacities support psychologically healthy living. Here are two important ones that research has confirmed.

Positive Emotions – We now know that you can train the brain to build new capacities, through meditation and “practice.” Among the most important for psychological health are empathy and compassion. These capacities enable to you develop greater wisdom and effectiveness in dealing with problems.

This reflects what researchers call the neuroplasticity of the brain. Recently, the eminent neurologist Oliver Sachs described the remarkable capacity of the brain to learn and regenerate. Research also shows that positive emotions increase your capacity for resilience by strengthening your ability to handle stress and adversity.

Broadened Perspectives – This is the capacity to step “outside” of yourself and view problems from an enlarged viewpoint, including that of people you disagree with. In a previous post I’ve used the term “constructive disengagement” to describe this as a positive way to handle relationship conflicts. Research shows that you can move forward, emotionally, when you detach yourself; that is, disengage from the emotions that have been stirred up. In fact, we now know that even the infant is able to recognize another’s point of view.

Another aspect of a broadened perspective that research confirms is that you can enhance your cognitive powers for problem-solving when you engage in positive rather than adversarial relations with others. Moreover, other research shows the positive benefit of simply behaving contrary to your usual personality traits — another form of stepping “outside” of yourself.

Of course, building positive emotions and enlarging your perspectives are intertwined. Actions that strengthen one also strengthen the other. These are just two capacities that I think are part of a psychological health, today. They support the behavior that will be increasingly recognized as essential for creating and building lives and institutions that sustain, grow and develop in our interconnected world. For example, being able to let go of purely self-interest as the driver of one’s relationships and work. Being flexible, transparent and nimble. Shifting and redeploying emotional, creative and other capacities towards positive engagement and collaboration, in order to achieve common goals. That is what supports both outward success and internal well being. And that’s psychologically healthy.

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UNC Researchers Investigate Estrogen Replacement Therapy To Prevent Depression And Cardiovascular Disease

Article Date: 13 Jan 2011 – 2:00 PST

Researchers at the University of North Carolina at Chapel Hill have launched a new clinical trial to determine if estrogen replacement therapy may help prevent depression and cardiovascular illness in women between the ages of 45 and 55.

It’s a move that may raise eyebrows in some quarters, given that a Women’s Health Initiative (WHI) study was halted in 2004 due to findings that estrogen therapy resulted in an increased risk of stroke and blood clots.

But there’s an important difference between the UNC study and the WHI estrogen study, said David Rubinow, MD, UNC’s chair of psychiatry and one of two principal investigators of the new 5-year study, which is funded by a $4.5 million grant from the National Institutes of Health. The other principal investigator is Susan Girdler, PhD, professor of psychiatry.

“The Women’s Health Initiative study led to the mistaken belief that estrogen replacement therapy is bad for all women. And as a result, it has served to deprive some women of a treatment that might greatly and favorably impact their lives. Much of the negative impact of estrogen that they found was related to the fact that most of the women in the Women’s Health Initiative study were far past the menopause and up to 79 years old,” Dr. Rubinow said.

“There are now a large number of studies that demonstrate what has been called the timing hypothesis. That is, giving estrogen within a year or two of menopause has beneficial effects, but giving estrogen in women more than five years beyond the menopause can actually be harmful.

“When the women who were close to menopause were looked at separately, the adverse effects on the heart were not seen and in fact some suggestion of beneficial effects was seen. Perimenopausal women in the Women’s Health Initiative who received estrogen had significantly lower coronary artery calcification compared to the women who didn’t take estrogen.

“That raises the question: Is estrogen potentially beneficial for women in the perimenopause – the years surrounding the menopause? It’s really an unanswered question at this point. Our study is an effort to find out what puts an individual woman at risk for heart disease and depression and what predicts beneficial effects of estrogen replacement during the perimenopause on affective well-being and cardiovascular well-being.”

The study, which began in August 2010 and will be conducted entirely at UNC, seeks to enroll a total of 320 women ages 45 to 55 who are in the menopause transition. All will be randomized to receive treatment with estradiol (estrogen replacement) skin patches or placebo.

Women in the study will be tested three times: before treatment and then again after 6 months and 12 months of treatment. These laboratory tests will measure their cardiovascular and inflammatory responses to mental stress, indicators of cardiovascular health and metabolic markers such as a glucose tolerance test, waist/hip ratio and lipid profiles. In addition, assessments of their moods, vital signs, side effects and compliance with the treatment regimen will be conducted on each participant

“Given the mortality and morbidity associated with depression and heart disease, and the tremendous increase in risk of these disorders during the perimenopause, it is critical that we identify those women who will be helped by estradiol,” Dr. Rubinow said.

The research study is currently enrolling participants. Eligible women will receive free study related medical evaluations and up to $1,200 in monetary compensation for completing all study visits.

University of North Carolina at Chapel Hill School of Medicine

View drug information on Estradiol Transdermal System.